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Head of Pharmacy VieCuri Medical Centre PO Box 1926 5900 BX Venlo, Netherlands fax 31-77-320 6001 lvdijk{at}viecuri.nl Department of Medical Informatics Radboud University Nijmegen Nijmegen, Netherlands
Hospital Pharmacist VieCuri Medical Centre Venlo, Netherlands
SIR Institute for Pharmacy Practice Research Leiden, Netherlands
Department of Clinical Pharmacy Radboud University Nijmegen Scientific Institute Dutch Pharmacists The Hague, Netherlands
Published Online, November 28, 2006. www.theannals.com, DOI 10.1345/aph.1H380
Methods. Additional data were collected from the Deventer Ziekenhuis, in Deventer, and Medisch Spectrum Twente, in Enschede, both regional teaching hospitals in the Netherlands. Neither hospital regularly monitored kidney function in relation to drug therapy during admission or at discharge. Medication records of all patients discharged through the discharge counseling service were screened for 30 days between April and May 2006 and analyzed as previously.1
Results. During the stated period, 252 and 299 patients, respectively, were discharged from the hospitals in Deventer and Enschede. Because there were no statistical differences in patient characteristics, the groups were combined for analysis. Nearly 31% (169) of the patients had a calculated creatinine clearance less than 51 mL/min/1.73 m2. These patients received 1106 medications. In 281 (25.4%) prescriptions, dosage adjustment was required according to renal function. This adjustment was made in 160 (56.9%) prescriptions. The other 121 (43.1%) drugs, representing the cases, were not adjusted.
There were no significant differences between cases and controls with respect to the variables of age, sex, duration of hospital stay, number of prescriptions, or physician specialty. Low creatinine clearance levels (<35 mL/min/1.73 m2) significantly increased the risk that a dosage adjustment was not performed (p < 0.05). The same association was found when the clinical relevance of the dosage adjustment was moderately severe or severe (Table 1).
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Discussion. In our research population at discharge, 25.4% of all prescribed drugs needed dosage adjustment according to renal function, which is comparable to the percentage (23.9%) we found previously.1 In 56.9% of the prescriptions needing adjustment, doses were adjusted according to guidelines; however, in 43.1% of the prescriptions needing adjustment, the standard dosage remained. Dosage adjustments were most often overlooked in the same drugs (eg, digoxin, metformin, angiotensin-converting enzyme inhibitors). These data are comparable to those of our previous study (Table 1).1
The same significant associations were found in relation to renal function and clinical need for adjustment. Worsening renal function (creatinine clearance <35 mL/min/1.73 m2) was associated with unperformed dosage adjustments (OR 0.413), which is comparable to the results found earlier (OR 0.47).1 The association between the consequences of nonadjustment and dosage adjustment per guidelines was exactly the same in both studies (OR 2.41). Therefore, we conclude that there are no geographical differences in the adjustment of drug dosage according to renal function at discharge.
In the studied population, although dosage adjustments were necessary in 25% of all prescriptions, they were performed in only 57% of those needed. The risk of not adjusting the dosage was significantly associated with a creatinine clearance of <35 mL/min/1.73 m2 and the necessity of dosage adjustments (p < 0.05), which duplicated earlier results. The similar findings and associations in different hospitals subscribe to the need for uniformity in dosing guidelines and the development of a general dynamic alert system as a tool to adapt drug dosing in patients with renal impairment.
Acknowledgments
We thank C Neef PharmD PhD, clinical pharmacologist, and I van Berlo-de Laar PharmD, clinical pharmacist, for offering insight into the medication records at discharge in their hospitals.
References
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